Healthcare Provider Details

I. General information

NPI: 1164261301
Provider Name (Legal Business Name): KIRSTEN MADICK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIRSTEN APPEL

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 S RACCOON RD STE 1
AUSTINTOWN OH
44515-5380
US

IV. Provider business mailing address

10 DUTTON DR
YOUNGSTOWN OH
44502-1899
US

V. Phone/Fax

Practice location:
  • Phone: 330-746-7691
  • Fax: 330-743-8368
Mailing address:
  • Phone: 330-746-7691
  • Fax: 330-743-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.007263
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: